The anesthesia workforce: Supply demand imbalance part 2
Myron Yaster MD, William J. Greeley MD, Aubrey Maze MD, and Joseph Carvero MD
“No matter what anyone says, it’s always about money” Mark Rogers MD
In yesterday’s PAAD, Abouleish et al.1 discussed the imbalance in anesthesia workforce supply and demand in the post COVID pandemic era. In part one we focused on emerging trends that affect the supply of the anesthesia work force including the aging workforce, changing workforce expectations and desires for work. In today’s part 2, we will focus on potential practice solutions including changes in how we deliver anesthesia and sedation services. Myron Yaster MD
Original article
Abouleish AE, Pomerantz P, Peterson MD, Cannesson M, Akeju O, Miller TR, Rathmell JP, Cole DJ. Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance. Anesthesiology. 2024 Jun 17. doi: 10.1097/ALN.0000000000005052. Epub ahead of print. PMID: 38884582.
Following the Covid pandemic the demand for anesthesia services has increased dramatically, particularly in non-operating room procedure locations like endoscopy and imaging suites in both hospitals and outpatient settings including doctor of medicine or dentistry offices. 2 For many adult and pediatric practices, non-operating room anesthesia makes up almost 30-50% of their practice volumes. For our adult colleagues, the focus of the article by Abouleish et al., the aging American population, places a huge demand on anesthesia providers because the elderly require an increasing number of surgeries and procedures, and often these patients are more complex and require more intensive resources for their care than younger patients. Abouleish et al. did not discuss pediatric anesthesiologists per se3, nor the special workforce issues in pediatric cardiac anesthesia,4 nor problems in low and middle income countries.5 Further, over the past 2 decades, major reductions (20-25%) have occurred in pediatric hospital capacity in general hospitals, particularly in rural areas. How or should we staff these areas? We know that increasingly the demand for pediatric anesthesiologists is now in regional children’s hospitals and outpatient centers that specifically treat children.6,7 The effects of these changes in manpower needs is not clearly understood. I (AM) do believe the authors should differentiate between the ASC and hospitals especially those that need call coverage. The issue of hospitals demanding increased coverage as well demands by work force not to work post call at all are escalating. For example, too many Trauma units demand coverage because hospitals generate increased revenue if they have a trauma unit. Then we get to peds cardiac anesthesia which is completely out of whack. Low volume Institutions paying locums 400 dollars an hour for availability not anesthesia time. The cycle is absolutely non-sustainable. (WG) The resultant higher salaries for pediatric cardiac anesthesiologists due to a required ACGME approved second year of fellowship, the critically low supply of these subspecialists and the higher call burden compared to general peds anesthesiologist, has an insidious impact on all pediatric anesthesia groups. The internal (within a local group) dynamics has created significant disruption and conflict within groups who must share resources, time, schedules, etc. As a consultant to anesthesia groups, this internal tension is a frequent request to address and solve.
Increasing the supply of anesthesiologists is a sisyphusian task (In the Greek legend, Sisyphus was condemned by the Gods to repeatedly roll a boulder up a hill only to have it roll down again once he got to the top.) As rapidly as we fill the tank, the actual number of available practitioners may fall because of retirement and changes in how Generation Y and Z value work–life balance. In other words, even if the total number of physicians remains the same, the total clinical capacity will still be reduced due to lower work hours per clinician.8
Perhaps how we staff is a better solution than simply trying to increase the numbers in the pipeline. When we were PICU attendings, we normally managed up to 18 critically ill patients at a time with 1:1 or 1:2 regular registered nurse (RN) coverage. Although we do not know an optimal staffing ratio for general anesthesia or deep sedation in pediatrics, the current models may need to be looked at and tested more closely. The current model of 1:1-1:4 coverage with MDs, CRNAs, AAs, and house staff may not be sustainable or necessary. Obviously, the optimal staffing ratio is determined by multiple factors, including the geographic location of sites, the medical comorbidity and age of the patients, and the complexity of the procedures. However, it is clear to us that many non-OR procedures, particularly those performed with a natural airway might easily be staffed by regular RNs (not CRNAs or AAs) with attending 1:4 or 1:6 (or more) supervision. Examples would include MRI, CT and PET scan imaging, oncology bone marrow aspirations with or without lumbar punctures, audiometry testing, and many other minor procedures like suture removal, botox injections etc.
Furthermore, as discussed in the recent PAAD on remimazolam (May 29.2024, https://ronlitman.substack.com/publish/posts/detail/144694925?referrer=%2Fpublish%2Fposts%3Fsearch%3Dremimazolam remimazolam or intranasal dexmedetomidine may be game changing and their use in sedation may not require an anesthesia provider at all.9 Obviously, this would revolutionize how we deliver care and staff. In other words, do we really need to use staff who have trained for years to provide general anesthesia for the sickest patients and most difficult procedures (think transplant!) need to be present for many simple sedation procedures? Regardless of how or if we change, “significant challenges to providing quality sedation, including ensuring that (1) sedation is being provided to appropriate patients; (2) sedation teams are properly trained, identify high-risk patients, and know when to call for help; and (3) program oversight is of high quality.”1
“Embedded in a moderate sedation program that provides a high level of patient safety is a well-documented process for screening patients for the appropriateness of the service. The anesthesiology department must be involved in developing the screening algorithm. One can envision that the highest quality sedation service would be designed to have the anesthesiologist in the immediate area (“command center”) of the sedation sites, evaluating patients who are screened to be at higher risk, available to assess ongoing sedation, and able to intervene when the sedation level is insufficient.”1
Abouleish et al conclude with the following proposed solutions:
1. Increase the pipeline and adapt training to emerging healthcare needs. Consideration should be given on a federal level to increasing the number of federally funded graduate medical education slots and to increasing training capacity through academic–community partnerships.
2. Facilitate retention through improvements in the workplace environment. The factors that affect retention include initiatives to address burnout, harassment, incivility, and violence; an inclusive culture; flexible scheduling; and transition to retirement that keep physicians in the workforce.
3. Improve capacity through innovations in practice. These include models for the more efficient delivery of moderate sedation in non–operating room settings and acuity or risk-based models that may allow for greater physician supervision ratios in low-acuity settings.
4. Leverage technology to aid in decision-making and improve the efficiency of care. Technology holds the promise to automate low-value tasks, increase the ability to supervise safely, and augment clinical skills. Consideration should be given to an annual technology summit, which would showcase emergent technologies and identify gaps and opportunities for further development.
5. Address financial constraints including deficiencies in Medicare payment for anesthesiologist services, development of mechanisms of payment for sedation services, and correction of inequities, particularly as related to rural access.
I (WJG) would add another perspective, where instead of viewing Anesthesia services as a cost center on a P&L, take a systems view. The procedural and technical fees that the system accrues and anesthesia services support, should be viewed as a service line where anesthesia is a fundamental and necessary component. As anesthesia director I can save the facility $1 – 2 million/yr. anesthesia subsidy by closing an OR or a NORA site permanently. However, from the facility perspective this will result in $20 – 25 million/yr. loss for the system. Go figure.
This issue of workforce supply and demand is an issue that I (JC) deal with most and impacts everything I do to manage my department. It is hard to motivate or put guardrails on faculty that know you are desperate for their clinical FTE, and that there are 10 other institutions that would take them in a second should they choose to change employment. I (WJG) believe that there will be just a few Institutions (mostly top rank Children’s Hospitals that have the resources [financial and human], independence and focus) that will lead the us through these challenging times for our subspecialty and maintain both our clinical and academic missions.
What do you think? We know that many items in our discussion of the article by Abouleish et al are controversial and may affect your income. Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Abouleish AE, Pomerantz P, Peterson MD, et al. Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance. Anesthesiology 2024. DOI: 10.1097/aln.0000000000005052.
2. Du AL, Robbins K, Waterman RS, Urman RD, Gabriel RA. National trends in nonoperating room anesthesia: procedures, facilities, and patient characteristics. Current opinion in anaesthesiology 2021;34(4):464-469. (In eng). DOI: 10.1097/aco.0000000000001022.
3. Muffly MK, Singleton M, Agarwal R, et al. The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035. Anesthesia and analgesia 2018;126(2):568-578. (In eng). DOI: 10.1213/ane.0000000000002535.
4. Nasr VG, Staffa SJ, Vener DF, et al. The Practice of Pediatric Cardiac Anesthesiology in the United States. Anesthesia and analgesia 2022;134(3):532-539. (In eng). DOI: 10.1213/ane.0000000000005859.
5. Niconchuk JA, Newton MW. Global pediatric surgery and anesthesia inequities: how do we have a global effort? Current opinion in anaesthesiology 2022;35(3):351-356. (In eng). DOI: 10.1097/aco.0000000000001122.
6. Mahant S, Guttmann A. Shifts in the Hospital Care of Children in the US—A Health Equity Challenge. JAMA network open 2023;6(9):e2331763-e2331763. DOI: 10.1001/jamanetworkopen.2023.31763.
7. Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA network open 2023;6(9):e2331807-e2331807. DOI: 10.1001/jamanetworkopen.2023.31807.
8. Holzer BM, Ramuz O, Minder CE, Zimmerli L. Motivation and personality factors of Generation Z high school students aspiring to study human medicine. BMC Med Educ 2022;22(1):31. (In eng). DOI: 10.1186/s12909-021-03099-4.
9. Barbosa EC, Espírito Santo PA, Baraldo S, Meine GC. Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis. British journal of anaesthesia 2024;132(6):1219-1229. (In eng). DOI: 10.1016/j.bja.2024.02.005.